Dual Heart-kidney Transplant With Total Abdominal Hysterectomy

Abstract

Introduction Dual heart and kidney transplantation (HKTx) is becoming an increasingly common surgical approach to selected patients with end-stage heart failure and end-stage renal disease. To date, there are no published reports of HKTx performed with near-concurrent total abdominal hysterectomy. Herein we present a case of a female patient who underwent successful HKTx with total abdominal hysterectomy. Case A 39 year old African American woman with a body mass index of 22 kg/m2 with significant uterine fibroids (figure 1), dilated cardiomyopathy from prior viral myocarditis, and chronic kidney disease was transferred to our institution for consideration of dual organ transplant.Upon transfer, the patient presented in SCAI shock Class D on dual inotropes. Despite the high doses of milrinone and dobutamine, her hemodynamics remained suboptimal with a blood pressure of 86/54 and heart rate of 130. Her exam was notable for elevated jugular venous pressure, cool extremities, and a loud systolic murmur with radiation to the apex. Labs revealed a sodium of 127meq/L and a worsening creatinine of 3.7mg/dL from a baseline of 2.5mg/dL. A right heart catheterization revealed elevated biventricular filling pressures and persistently low cardiac index (1.5 L/min/m2). She required the addition of epinephrine and a balloon pump for stabilization.She was then presented for an urgent heart and kidney transplantation, but given significant uterine fibroids, and relatively small BMI and waist circumference, gynecological surgery was consulted for need of total abdominal hysterectomy for the placement of the kidney. A planned surgical approach, to include orthotopic heart transplantation with concurrent total abdominal hysterectomy, followed by next-day kidney transplant, was devised. The patient was counseled regarding future inability of pregnancy. She was successfully transplanted with no intraoperative complications. On post-op day 10, the patient developed hemoperitoneum that required exploratory laparotomy with the evacuation of hemoperitoneum and re-suturing of the vaginal cuff. She was discharged 18 days after transplant. Her follow-up to date has been uneventful. Conclusion Our case demonstrates that heart and kidney transplantation with total abdominal hysterectomy is a safe and effective method in patients with a small BMI and enlarged leiomyoma that may prohibit implantation of the donor kidney. Dual heart and kidney transplantation (HKTx) is becoming an increasingly common surgical approach to selected patients with end-stage heart failure and end-stage renal disease. To date, there are no published reports of HKTx performed with near-concurrent total abdominal hysterectomy. Herein we present a case of a female patient who underwent successful HKTx with total abdominal hysterectomy. A 39 year old African American woman with a body mass index of 22 kg/m2 with significant uterine fibroids (figure 1), dilated cardiomyopathy from prior viral myocarditis, and chronic kidney disease was transferred to our institution for consideration of dual organ transplant.Upon transfer, the patient presented in SCAI shock Class D on dual inotropes. Despite the high doses of milrinone and dobutamine, her hemodynamics remained suboptimal with a blood pressure of 86/54 and heart rate of 130. Her exam was notable for elevated jugular venous pressure, cool extremities, and a loud systolic murmur with radiation to the apex. Labs revealed a sodium of 127meq/L and a worsening creatinine of 3.7mg/dL from a baseline of 2.5mg/dL. A right heart catheterization revealed elevated biventricular filling pressures and persistently low cardiac index (1.5 L/min/m2). She required the addition of epinephrine and a balloon pump for stabilization.She was then presented for an urgent heart and kidney transplantation, but given significant uterine fibroids, and relatively small BMI and waist circumference, gynecological surgery was consulted for need of total abdominal hysterectomy for the placement of the kidney. A planned surgical approach, to include orthotopic heart transplantation with concurrent total abdominal hysterectomy, followed by next-day kidney transplant, was devised. The patient was counseled regarding future inability of pregnancy. She was successfully transplanted with no intraoperative complications. On post-op day 10, the patient developed hemoperitoneum that required exploratory laparotomy with the evacuation of hemoperitoneum and re-suturing of the vaginal cuff. She was discharged 18 days after transplant. Her follow-up to date has been uneventful. Our case demonstrates that heart and kidney transplantation with total abdominal hysterectomy is a safe and effective method in patients with a small BMI and enlarged leiomyoma that may prohibit implantation of the donor kidney.